MN Minnesota Homeowners Insurance Rate Quote Condominum Townhouse Renters Dwelling Fire AAA Kemper Auto Owners Encompass Midwest Family Mutual Western National

www.insuremn.com

Michael W. Smith Agency

Revised:

May 06, 2015

763-535-7293

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	Let me know about any special circumstances you have, such as a swimming pool, wood burning stove, credit problems, etc.

For Homeowners, Condominium / Townhouse Owners & Renters Insurance Quotes, please complete the form below.

This is a request for a Minnesota homeowners quote, not a policy application. Submitting this form does not obligate you to purchase any homeowners or renters insurance products. Please complete this form as accurately as possible. Homeowner insurance rates are subject to change.

General Information

Name
Street
City, State ZIP
County Located
E-mail
Phone
Fax:
Send information by:

Current Insurance Information

Insurance Company	Expiration Date

Dwelling Information

Occupancy	Usage

Type	Construction

Property Coverage Information

Dwelling Amount	Contents	Other Structures

Deductible	Personal Liability	Medical Payments

Scheduled Property

Jewelry	$	Furs	$
Fine Art/Antiques	$	Guns	$
Silverware	$	Golf Equipment	$
Musical Instruments	$	Cameras	$
Computer Equipment	$	Stamps/Coins	$

Dwelling Protection

Responding Fire Department	Miles to Fire Department	Feet to Fire Hydrant

Fire Alarm	Fire Sprinkler System	Burglar Alarm
Hold "Ctrl" key down to make multiple selections		Hold "Ctrl" key down to make multiple selections

Applicant's Underwriting Information

Date of birth	Marital Status	Social Security Number

Current address if different from dwelling address

Dwelling Underwriting Information

Date Purchased	Year Built	Year Heating Updated

Year Wiring Updated	Year Roof Updated	Year Plumbing Updated

Fireplace	Woodstove	Swimming Pool
Yes No	Yes No	Yes No
Claims Last 3 Years	What Happened & Amount Paid
Yes No

Additional Comments

Number of hits since August 15, 1998


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